Psychiatric Advance Directives Research Articles

Development of a Patient-Centred Care Plan for Patients Requiring Maintenance Electroconvulsive Therapy Long-Term

IntroductionMaintenance electroconvulsive therapy (ECT) can be effective and necessary in the long-term for patients with severe and recurrent mood or psychotic disorders that are not amenable to any other forms of treatment. Patients with such treatment resistance affecting their ability to maintain minimal daily activities may eventually fall within the palliative psychiatric care domain in which advanced medical directives become an important beacon to direct care. There are Psychiatric Advance Directives which allow people with severe mental health conditions to consent to or refuse to consent to hospital admission and psychiatric treatment in the event they lose decision-making capacity and this can be especially important for a potentially controversial treatment such as ECT. However, the focus tends to be on enforcing involuntary treatment and less about a comprehensive long-term care plan. To our knowledge, there is no available framework to structure maintenance ECT as a patient-centred care plan.ObjectivesOur aim is to share the process of development of a patient-centred care plan for patients requiring maintenance ECT. Our objectives are: 1.Constant engagement with patients and family or caregivers2.Regular reviews of clinical and consent aspects of treatment3.Advocating for the welfare of patients and respect of values4.Focus on dignity especially for patients who require treatment well into old age5.Being prepared for termination of treatment if necessary MethodsWe reviewed our management of previous and existing patients on maintenance ECT and incorporated diligent consent-taking practices. Adopting good practices from known palliative approaches and involving the patient voice helped to form a framework for a patient-centred care plan.ResultsOur patient-centred care plan features half-yearly discussions about the risks and benefits of treatment, as well as an assessment of the patient’s cognition and ability to consent which may change over time. Opportunities for them to share their values and expectations of care and engagement with their caregivers about their quality of life guide the continued treatment. A framework for discussing the disruption or eventual termination of ECT prepares for scenarios where older-aged patients may develop frailty or present with acute, prolonged or devastating medical concerns. This end-of-life care approach manages anticipated psychiatric-specific behavioural concerns and prepares for the possibility of death following the planned termination of ECT for patients who required long-term treatment throughout their life. Lastly, issues of grief amongst caregivers and ethical concerns from medical staff are addressed.Conclusions We hope that our patient-centred care plan provides a well-considered conversation and structure for the initiation, continuation and termination of maintenance ECT in the long-term.Disclosure of InterestNone Declared

Reproductive psychiatric advance directives: promoting autonomy for perinatal people with serious mental illness diagnoses.

People with serious mental illness (SMI) diagnoses who become pregnant are particularly vulnerable to symptom recurrence and resulting potential lack of decision-making capacity (Taylor et al. J Psychiatr Res 104:100-107, 2018; Bagadia et al. Int J Soc Psychiatry 66:792-798, 2020). In these situations, prenataland behavioral health providers have little legally viable guidance on what medical and/or psychiatric care the patient desires (Aneja and Arora Indian J Med Ethics V:133-139, 2020). We created a "Reproductive Psychiatric Advance Directive (PAD)," grounded in Reproductive Justice principles, that promotes patient autonomy by proactively articulating perinatal medical and psychiatric care preferences. We conducted a medical and legal literature review using two sets of terms related to (1) PADs and (2) reproductive health. We convened an expert working group of legal, medical, psychiatric, peer, and advocacy leaders and community-based organizations to develop a Reproductive PAD. Our literature review yielded no results about Reproductive PADs. We created de novo a Reproductive PAD template with sections on medical and psychiatric history, informed consent for critical medical and psychiatric care, family planning and custody preferences, and optional sections on abortion and on electroconvulsive therapy. The Reproductive PAD provides a possible legal mechanism for people of childbearing age with SMI diagnoses to articulate their medical and psychiatric care choices around reproduction and pregnancy. Future research should evaluate the Reproductive PAD as an effective tool for protecting patient autonomy during pregnancy and postpartum and guiding medical and psychiatric providers.

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Protecting the Autonomy of Patients with Severe Mental Illness Through Psychiatric Advance Directive Peer-Facilitation

Steering clear of Akrasia: An integrative review of self-binding Ulysses Contracts in clinical practice.

In many jurisdictions, legal frameworks afford patients the opportunity to make prospective medical decisions or to create directives that contain a special provision forfeiting their own ability to object to those decisions at a future time point, should they lose decision-making capacity. These agreements have been described with widely varying nomenclatures, including Ulysses Contracts, Odysseus Transfers, Psychiatric Advance Directives with Ulysses Clauses, and Powers of Attorney with Special Provisions. As a consequence of this terminological heterogeneity, it is challenging for healthcare providers to understand the terms and uses of these agreements and for ethicists to engage with the nuances of clinical decision-making with such unique provisions surrounding patient autonomy. In theory, prospective self-binding agreements may safeguard patient's "authentic" wishes from future "inauthentic" changes of mind. In practice, it is unclear what may be comprised within these agreements or how-and to what effect-they are used. The primary focus of this integrative review is to curate the existing literature describing Ulysses Contracts (and analogous decisions) used in the clinical arena, in order to empirically synthesize their shared essence and provide insights into the traditional components of these agreements when used in practice, the requirements of their consent processes, and the outcomes of their utilization.

Cultural Influences on the Creation and Use of Psychiatric Advance Directives.

Little published research exists on how culture influences mental health service users when they create or use psychiatric advance directives (PADs). This column reports the results of a study (N=38 participants) of cultural factors that might encourage New Zealand Māori who engage in mental health services to make greater use of PADs in their care. The most important factor identified was the inclusion of family and friends in decision making during PAD creation and use. Discussions revealed multiple culturally important themes that were synthesized into a conceptual model, pou herenga (mooring place), which focuses on the importance of reassessing all aspects of one's life journey when creating a PAD.

Psychiatric Advance Directives: A Call for Humanization

Psychiatric Advance Directives: A Call for Humanization

APA Resource Document Outlines Principles on Use of Seclusion, Restraint

APA Resource Document Outlines Principles on Use of Seclusion, Restraint

Advance statements in mental healthcare: time to close the evidence to practice gap.

This article discusses advance statements in mental health care, which allow individuals with mental disorders to express their preferences for treatment during mental health crises. Despite the evidence supporting their effectiveness, their implementation in clinical practice remains limited. This article explores variations among advance statements, such as psychiatric advance directives (PADs), joint crisis plans (JCPs) and self-binding directives (SBDs), highlighting their content, development process and legal status. We outline the benefits of advance statements, including empowerment, early intervention, improved therapeutic relationships and reduced compulsory admissions. We then draw attention to the challenges that may contribute to their lack of implementation, including legal complexities, communication issues, cultural factors, potential inequities, healthcare provider knowledge, changing preferences, resource constraints, crisis responses, data privacy, family involvement, and long-term evaluation. In conclusion, advance statements offer significant benefits but require addressing these critical aspects to ensure ethical and effective use. Bridging the evidence-to-practice gap is essential, with a focus on implementation science. Integrating these tools into routine clinical practice can significantly benefit individuals with severe mental disorders and mental health systems.

Psychiatric advance directives and consent to electroconvulsive therapy (ECT) in Australia: A legislative review and suggestions for the future

Psychiatric Advance Directives (PADs) have been adopted in many jurisdictions around the world and in most Australian states and territories. They are seen as a less restrictive and patient-centered approach to the provision of mental health care. Electroconvulsive therapy (ECT) is a restricted treatment in most jurisdictions in Australia and across the world. This paper explores the history, regulation and use of ECT and PADs and the intersections between them. It provides an overview of the legislative framework in each Australian state and territory and explores some of the issues which have arisen such as complexity of the regulatory framework, making PADs binding for refusing and consenting to ECT, involving treating teams in how PADs are made, using restrictive interventions to implement PADs, and the role of the Tribunal. While PADs are often framed as an important legal tool for allowing patients to refuse psychiatric treatment (especially ECT), the paper emphasizes that they can also be an innovative way for people to consent to psychiatric treatment in advance and an empowering option to access mental health care. It then makes some suggestions for future reform.

Medical Orders for Life-Sustaining Treatment in Correctional Settings.

Medical Orders for Life-Sustaining Treatment in Correctional Settings.

Effect of Psychiatric Advance Directives Facilitated by Peer Workers on Compulsory Admission Among People With Mental Illness

Reducing the use of coercion in mental health care is crucial from a human rights and public health perspective. Psychiatric advance directives (PADs) are promising tools that may reduce compulsory admissions. Assessments of PADs have included facilitation by health care agents but not facilitation by peer workers. To determine the efficacy of PADs facilitated by peer workers (PW-PAD) in people with mental disorders. A multicenter randomized clinical trial was conducted in 7 French mental health facilities. Adults with a DSM-5 diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who had a compulsory admission in the past 12 months and the capacity to consent were enrolled between January 2019 and June 2020 and followed up for 12 months. The PW-PAD group was invited to fill out a PAD form and meet a peer worker who was trained to assist in completing and sharing the form with relatives and psychiatrists. The primary outcome was the rate of compulsory admission at 12 months after randomization. The overall psychiatric admission rate, therapeutic alliance, quality of life, mental health symptoms, empowerment, and recovery outcomes were also investigated. Among 394 allocated participants (median age, 39 years; 39.3% female; 45% with schizophrenia, 36% bipolar I disorder, and 19% schizoaffective disorder), 196 were assigned to the PW-PAD group and 198 to the control group. In the PW-PAD group, 27.0% had compulsory admissions compared with 39.9% in the control group (risk difference, -0.13; 95% CI, -0.22 to -0.04; P = .007). No significant differences were found in the rate of overall admissions, therapeutic alliance score, and quality of life. Participants in the PW-PAD group exhibited fewer symptoms (effect size, -0.20; 95% CI, -0.40 to 0.00), greater empowerment (effect size, 0.30; 95% CI, 0.10 to 0.50), and a higher recovery score (effect size, 0.44; 95% CI, 0.24 to 0.65), compared with those in the control group. Peer worker-facilitated PADs are effective in decreasing compulsory hospital admissions and increasing some mental health outcomes (self-perceived symptoms, empowerment, and recovery). Involving peer workers in the completion of PADs supports the current shift of mental health care from substitute decision-making to supported decision-making. ClinicalTrials.gov Identifier: NCT03630822.

Facilitation of Psychiatric Advance Directives by peer-workers: results from DAiP

Introduction United Nations Convention on the Rights of Persons with Disabilities recognized that people with psychosocial disabilities have the same right to take decisions and make choices as other people. Consequently, direct or supported decision-making should be the norm and there should be no substitute decision-making. However, these principles are far from common practice in many mental health services. Joint-crisis plan (JCP) and Psychiatric advance directives (PAD) are interesting tools to translate the shared-decision making principle into clinical and practical reality. Most existing JCP or PAD involve facilitators, which improves their effectiveness, but facilitators are mostly professionals.ObjectivesIn this context, DAiP study was launched to evaluate the efficacy of PAD facilitated by peer-workers.MethodsDAiP was a multicenter randomized controlled trial conducted in 7 French mental health facilities, with a complementary qualitative approach. 394 adults with a DSM-5 diagnosis of schizophrenia (SCZ), bipolar I disorder (BP-I), or schizoaffective disorders (SCZaff ), who were compulsorily hospitalized in the past 12 months were enrolled from January 2019 and followed up for 12 months. Outcomes were compulsory admission rate, therapeutic alliance (4-PAS), quality of life (S-QOL), mental health symptoms (MCSI), empowerment (ES) and recovery (RAS).ResultsIn this communication, we propose to describe the practices of facilitation of peer-workers and analyze outcomes in lights of process measurements (whether or not participants completed PAD document, shared PAD and with whom, met facilitator, used PADConclusionsInvolving peer-workers in the redaction of PADs coherently supports the current shift of mental health care from ‘substitute decision making’ to ‘supported decision making’.DisclosureNo significant relationships.

SMI Adviser to Offer Virtual Learning Collaboratives

Back to table of contents Previous article Next article ProfessionalFull AccessSMI Adviser to Offer Virtual Learning CollaborativesMark MoranMark MoranSearch for more papers by this authorPublished Online:14 Oct 2021https://doi.org/10.1176/appi.pn.2021.11.17AbstractSMI Adviser offers free CME/CE-certified education, expert consultations, and resources to help frontline clinicians and staff provide evidence-based care to individuals who have serious mentaI illness.SMI Adviser, APA’s Clinical Support System for Serious Mental Illness, will offer 10 free virtual learning collaboratives beginning in February 2022. These 12-week courses provide in-depth information on specific topics related to caring for patients with serious mental illness (SMI). Each course is guided by experts in SMI.SMI Adviser was funded in July 2018 by a five-year, $14.2 million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). It offers free CME/CE-certified education, expert consultations, and resources to help frontline clinicians and staff—including physicians, nurses, psychologists, social workers, counselors, and peer recovery specialists—provide evidence-based care to individuals who have SMI, including those living with schizophrenia, bipolar disorder, or major depressive disorder.The virtual learning collaboratives that launch in the spring include the following:Getting Started Building Your Clozapine PracticeProtocol-Driven System to Manage Efficacy and Side Effects of ClozapineGetting Started with Telehealth for Serious Mental IllnessGetting More From Telehealth: Increasing Engagement and Supporting Remote Diagnostics and InterventionsMotivational Interviewing for People With Serious Mental IllnessImplementing Tools for Symptom and Functional Assessment of Individuals With SMIBuilding and Using a Comprehensive Psychiatric Mental Health Nursing AssessmentTreating the Whole Patient: Addressing the Physical Health Needs of Populations With SMIThese learning collaboratives are an ideal opportunity to build skills using an intensive, real-world, evidence-based approach. Clinicians can consult with faculty experts and get real-time feedback during virtual office hours, participate in group calls with colleagues, complete skills-based assignments, and share ideas on interactive discussion boards. The time invested in these courses helps translate skills directly from concept into actionable care for individuals with SMI.SMI Adviser offers a wealth of information in addition to its virtual learning collaboratives. It is free and accessible via website and a smartphone app. This allows clinicians to easily obtain consultation from experts, access tools that support care, and earn CME/CE credits. SMI Adviser’s online education catalog includes more than 200 webinars and interactive modules on a wide range of subjects on SMI—among them, the interface between SMI and the criminal justice system, the use of telepsychiatry for treating patients with SMI, engagement of patients and families in treatment planning, strategies for successful use of clozapine, use of psychiatric advance directives, and chronic physical health management for individuals with SMI.Last year SMI Adviser released My Mental Health Crisis Plan, a mobile app that includes a step-by-step guide for people with SMI to create a psychiatric advance directive (PAD) and share their treatment preferences in advance of a mental health crisis. A PAD is a legal document that details an individual’s treatment preferences in the event they are unable to make decisions due to worsening illness.SMI Adviser also operates two Centers of Excellence (CoEs) to promote best practices in psychopharmacology—the Clozapine Center of Excellence and Long-Acting Injectable Center of Excellence. Each is dedicated to providing free CME/CE-certified education, consultations, resources, and other evidence-based tools.The CoEs host a community listserv and monthly virtual forums for moderated peer-to-peer discussions on trending topics on either clozapine or long-acting injectable medications. Clinicians can engage with colleagues and share challenges and questions on the month’s trending topic. Virtual forums are held from 4 p.m. to 4:45 p.m. ET on the first Wednesday of every month. Those interested in participating may sign up to receive email invitations at the Clozapine Center of Excellence or Long-Acting Injectable Center of Excellence.APA CEO and Medical Director Saul Levin, M.D., M.P.A., said that SMI Adviser breaks new ground in using technology to bring expert advice on SMI to clinicians who need it.“I urge our members and mental health professionals to visit the SMI Adviser website and download the app and explore this remarkable resource,” he said. “It’s a huge step in realizing the vision of the SAMHSA grant to bring customized, evidence-based information to those caring for patients with SMI.” ■ ISSUES NewArchived

533 - “Agitation and End-of-Life: Towards an Advance Directive that Prepare for Agitation and Behavioral Symptoms in Alzheimer’s Disease”

AbstractAdvance Directives provide legal documentation of a person’s wishes regarding medical treatment and care, allowing people and their families to decide in advance how care and treatment should be provided at end-of-life when a person is no longer capable of making independent decisions. For people living with advanced stages of Alzheimer’s, Advance Directives give specific, life-altering instructions to ensure a person’s will is being met. Yet Advance Directives that anticipate for the eventualities of Alzheimer’s Disease often fail to specifically prepare for the care and treatment decisions prompted by agitation and other behavioral aspects of the disease. This is a major oversight.“Agitation and End-of-Life: Towards an Advance Directive that Prepare for Agitation and Behavioral Symptoms in Alzheimer’s Disease” proposes a framework for how Advance Directives can prepare for the unique decisions that arise as a person experiences agitation and other behavioral symptoms of Alzheimer’s.The framework proposed in this project draws from the recent development of Psychiatric Advance Directives led in part by the American Psychiatric Association, which have pioneered the use of Advance Directives for anticipated behavioral challenges. Specifically, Psychiatric Advance Directives allow individuals to specify in advance which treatments may be administered in response to acute episodes of psychiatric illness at a time when someone is unable or unwilling to provide consent. Our project contends that the mechanisms underlying Psychiatric Advance Directives be modeled but modified to help people, families, and providers prepare for agitation and the behavioral aspects of Alzheimer’s.Specifically, we propose a four-part framework for Advance Directives to prepare for agitation and other behavioral aspects of Alzheimer’s: 1.Psychiatric medications. What treatments may – or may not – be used to manage agitation or other behavioral disturbances?2.Agitation prevention and de-escalation. What strategies and techniques can caregivers employ to mollify agitated behaviors? How should caregivers respond to episodes of agitation?3.Lifestyle preferences and values. What values – religious or otherwise – should guide care and treatment?4.Information sharing and access. When and how should caregivers, medical professionals, and family members be notified – or share information about – behavioral disturbances?It is well established in the scientific and medical literature that agitation and behavioral aspects of Alzheimer’s can cause severe difficulty for families as the disease progresses. Advance Directives that prepare for agitation can help to create a plan and ease the challenges prompted by agitation and other behavioral aspects of Alzheimer’s.

The Right to Choose

The Right to Choose

Appropriateness of psychiatric advance directives facilitated by peer support specialists and clinicians on Assertive Community Treatment teams

Background Psychiatric advance directives (PADs) are used to document a person’s treatment preferences for a future mental health crisis. Peer support specialists have been proposed to facilitate PADs, but little is known about the quality of peer versus clinician facilitated PADs. Aims This study examined whether PAD documents facilitated by peer specialists and non-peer clinicians differed in the mix of treatment requests and refusals and expert ratings of feasibility and consistency. Methods Analyses were conducted of content and expert ratings of 72 PAD documents from a randomized trial of PAD facilitation by peers and clinicians on Assertive Community Treatment (ACT) teams. A count of treatment refusals and requests was used to classify documents as predominantly prescriptive, proscriptive, or balanced. Regression was used to estimate relationships between PAD facilitator type and content. Results Peer-facilitated PADs were significantly more likely to be predominantly prescriptive than were PADs facilitated by non-peer clinicians. Prescriptive PADs were more likely to receive expert ratings of high feasibility and consistency. Conclusions Results should alleviate some clinicians’ apprehensions regarding the appropriateness of peer-facilitated PADs, such as the concern that people with lived experience with mental illness might encourage other consumers to use their PAD primarily for treatment refusals.

Psychiatric Advance Directives and Artificial Intelligence: A Conceptual Framework for Theoretical and Ethical Principles.

The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.

Implementing Psychiatric Advance Directives: The Transmitter and Receiver Problem and the Neglected Right to Be Deemed Incapable.

Psychiatric advance directives (PADs) can help adults with serious mental illnesses preserve their autonomy and avoid involuntary interventions during an incapacitating mental health crisis. A PAD is a legal document prepared while mentally competent and states the person's treatment preferences to be implemented during a future crisis, ideally with the advocacy of an authorized proxy decision maker. PADs have been available in the United States for more than three decades but have yet to be robustly implemented in practice. This Open Forum describes PADs metaphorically as a device for remote communication among the person with mental illness, a proxy decision maker, and health care providers. Barriers to PAD usage occur on both "transmitter" and "receiver" sides and must be addressed to advance PAD implementation.

Psychiatric Advance Directives as an Ethical Communication Tool: An Analysis of Definitions

A psychiatric advance directive (PAD) is a communication tool that promotes patients' autonomy and gives capacitated adults who live with serious mental illnesses the ability to record their preferences for care and designate a proxy decision maker before a healthcare crisis. Despite a high degree of interest by patients and previous studies that recommend that clinicians facilitate the completion of PADs, the rate of implementation of PAD remains low. Research indicates that many clinicians lack the necessary experience to facilitate the completion of PADs and to use them, and, as a consequence, do not effectively engage patients about PADs. This study developed practical recommendations for clinicians to improve their ability to communicate and facilitate PADs. We (1) thematically analyzed definitions of PADs published in 118 articles across disciplines, and (2) presented our recommendations for enhanced communication in clinical practice that emphasizes patient-centeredness, usefulness, and clarity, aligned with evidence-based practices that put patients' autonomy and understanding first. While there is no one-size-fits-all script to engage patients in complex conversations, our recommended strategies include an emphasis on patients' autonomy, the adaptation of word choices, the use of metaphor not simile, and checking for patients' understanding as effective methods of clinical communication.

Help and Hindrances to Completion of Psychiatric Advance Directives.

Psychiatric advance directives (PADs) allow service users to participate in their own mental health care in the event that they have a future mental health crisis and are deemed incompetent to make decisions, but few patients complete these documents. This Open Forum reports on factors that have helped or hindered completion of PADs in New Zealand. Perceived barriers to completion include resource limitations, procedural issues, access and storage problems, and mistrust between clinicians and service users regarding implementation. Having management and nursing "champions" of the process and organizing outreach meetings for all interested parties appear to aid completion. Targeted education and training promote creation and use of PADs, address negative attitudes, and assist service users in creating these documents. Information technology support is vital to having PADs uploaded and accessed in medical records.